Medicare is a federal health insurance program that was first introduced in 1965. It is primarily focused on people aged 65 or older, younger people with specific disabilities, and people who suffer from End-Stage Renal Disease (ESRD).
As of October 2021, Medicare had a staggering total enrollment of almost 64 million people. And there’s no surprise as to why so many people trust Medicare. Under their Original Medicare plan, Medicare covers a wide range of tests and services related to hospital insurance (Part A) and medical insurance (Part B).
This includes coverage from hospital care, home health care, clinical laboratory tests, doctor services, healthcare provider services, and diagnostic blood tests. For additional coverage, Medicare Advantage plans cover Part A & Part B and prescription drugs and other services.
However, there are a few categories of tests that Medicare will not cover. Since you want to be best prepared when visiting your doctor, it’s essential to know what these are beforehand.
Therefore, this article will explore what lab tests are not covered by Medicare, what to do if a test you need is not covered, and who will bear the costs if you proceed with it.
What lab tests are not covered by Medicare?
Medicare will generally cover most lab tests, but there are a few categories of tests that they won’t. These include most screening tests, tests that are not deemed medically necessary, tests that are performed too often, and tests that are ‘experimental’.
If you want to proceed with a test that is not covered, you will either have to pay for it out of pocket or claim it under additional insurance if you have it.
Just because Medicare will not pay for your test, that does not mean you don’t need it. As we’ll discuss in detail below, the opinion of Medicare and your doctor’s opinion may differ.
You could be in a situation where, from your doctor’s perspective, a particular test could be vital for your diagnosis, but Medicare will have the final say on whether they will cover it or not. Let’s examine the different tests Medicare won’t cover and the reasons why.
Screening tests refer to tests that are done to detect a disease or disorder in people who do not have or show any symptoms. In other words, pre-emptive or preventative tests; most of these are not covered under Medicare.
For example, your routine biannual blood test would be classed as a screening test and would therefore not be covered under the scope of Medicare Part B. However, that doesn’t mean all screening tests are ineligible.
There are still several medical tests that it covers, such as diabetes screenings, glaucoma tests, and lung cancer screening, to name a few. You can find the complete list and check which screening tests are covered.
Tests that are not deemed medically necessary
In Medicare’s opinion, some tests are medically necessary for a specific diagnosis or condition – for instance, medically necessary blood tests for diabetes – but others are not.
The critical distinction here is that it is in Medicare’s opinion; while your doctor may believe that a test is considered medically necessary, Medicare will not accept this as evidence or proof. That is why it can be slightly more confusing to determine whether your test is essential or not.
Luckily, you don’t have to cross your fingers and hope for the best. Medicare has a list of diagnosis codes that outlines tests that they will pay for. If your test is on this list, Medicare will cover it. If it is not, they could deny payment, and you may have to foot the bill.
Experimental – or investigational – tests are considered to be those that have not yet been approved by the U.S. Food & Drug Administration (FDA). For instance, a blood chemistry test using equipment or a device that has not been cleared for safety or efficiency would be regarded as experimental.
As a result, it would not be covered under Medicare. As mentioned above, a test must be medically necessary, and in Medicare’s view, an experimental test does not check that box since there is no guarantee of the test’s safety and/or efficiency.
Tests that are performed too often
Medicare has general recommendations as to how often specific tests should be performed. The frequency at which your doctor will recommend for you to undergo a test will depend on your diagnosis. Therefore, it isn’t straightforward enough to provide a blanket statement on this. However, if your doctor’s recommendations are too frequent compared to what Medicare suggests, then your tests may not be covered.
What happens if a test recommended by my doctor is not covered by Medicare?
If the lab or service provider of the test – your doctor, physician, etc. – believes that your test may not be covered under Medicare, they will give you an Advance Beneficiary Notice (ABN). An Advance Beneficiary Notice is a waiver of liability.
It will inform you that Medicare is unlikely to cover the costs of your test. It will also outline the reason as to why they expect Medicare will deny payment of your test, for instance, because it is medically unnecessary. And finally, it will state that in the event that you proceed with the test and Medicare denies payment, you will be personally and entirely responsible for the costs.
This means that you will either have to pay for the test out of pocket or claim it under additional insurance that you may have.
To proceed with the testing procedure, you will be required to select the option that accepts responsibility for the costs if Medicare doesn’t cover it and then sign and date the ABN waiver.
However, if you decide not to proceed with the test, the ABN provides you with an option to refuse the test altogether, which you can select.
Some tests can be very costly, whereas others may be much more affordable. If you don’t have an additional insurance policy in place, the medical bills could be pretty expensive. As such, whether proceeding with the test is financially viable for you or not will depend entirely on what test you require and your financial situation.
However, before making a decision, this is something that should be consulted with your doctor first. It’s vital to ensure that the best course of action you take has your medical health as the priority.
Is Medicare coverage the same throughout the country?
Whether you are on the Original Medicare plan or the Medicare Advantage plan, coverage for tests, services, and items will vary from state to state. If Medicare does not cover a particular lab test or service in your state, you may find that it’s covered in a neighboring one.
There are numerous urgent care tools available online which can help you find a healthcare provider throughout the country that will accept Medicare and provide the lab test you need. It’s also a good idea to check with your local healthcare provider for more information on this since they may have locations in another state that will be able to assist you.
Medicare covers blood tests, diagnostic tests, and most other lab tests related to a diagnosis. As long as the test is not a screening test, it’s not medically unnecessary, it’s not experimental, and it doesn’t occur too often, Medicare should cover it. Even then, there are some exceptions, as mentioned in this article.
If you find that your lab test is not covered, you still have the option of checking to see if the same lab test is covered under Medicare in another state. Medicare coverage will differ from state to state, and it’s worth exploring if you don’t want to fork out the total costs of the test yourself.
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